More than 450 patients died prematurely in a British hospital after they were given powerful painkillers for no medical reason in what a damning report found was a "disregard for human life".
An independent panel found that between 1989 and 2000 at the Gosport War Memorial Hospital in southern England, there was an institutionalised regime of prescribing and administering dangerous doses of opioids which were not clinically justified.
"There was a disregard for human life and a culture of shortening the lives of a large number of patients," the report said, adding that warnings from nurses had been ignored and there had been a failure by police and medical regulators to protect patients.
It added: "The families, and indeed the nation as a whole, are entitled to ask how these events could have happened; how the hospital dismissed the nurses' concerns and subsequently took no action; how the healthcare organisations failed to intervene.
We draw a distinction because Harold Shipman acted alone, apparently, whereas what we are describing to you in this report is an institutionalised practice and that is a significant difference
It could also be asked: "How the professional regulators allowed matters to continue; how the police failed to get to the bottom of what had happened and whether what happened is to be explained as a conspiracy or in some other way."
The 387-page report concluded that 456 patients were given opioids without justification and "probably at least another 200 patients similarly affected but whose clinical notes were not found".
Health Secretary Jeremy Hunt told parliament police would work with the prosecutors to "carefully examine the new material in the report and whether criminal charges will now be brought".
The report noted the Gosport deaths and the concerns raised about them occurred at the same time as it was revealed that British family physician Harold Shipman, dubbed "Dr Death" had been responsible for killing patients in his care with lethal heroin injections.
Shipman, convicted in 2000 for murdering 15 patients, killed as many as 250 people in his care according to a later inquiry. But the panel examining the Gosport scandal said the circumstances were different.
"We draw a distinction because Harold Shipman acted alone, apparently, whereas what we are describing to you in this report is an institutionalised practice and that is a significant difference," Reverend James Jones, the chairman of the independent panel, told reporters.